Treatment of symptoms associated with bacterial vaginosis

ABSTRACT

The invention relates to the use of saccharide, such as lactose for the preparation of a medicament for the treatment and/or prophylaxis of one or more symptoms caused by bacterial vaginosis, wherein the medicament comprises at least 20 percent by weight of saccharide, and wherein the medicament is substantially free from bacteria. Furthermore, the invention relates to a method for treating one or more symptoms associated with bacterial vaginosis, as well as a pharmaceutical composition comprising the saccharide.

REFERENCE TO RELATED APPLICATION

This application is a continuation of U.S. patent application Ser. No.10/560,519, which is a U.S. national stage of PCT/DK2004/00410, filedJun. 11, 2004, which claims priority to Danish application No.PA200300885, Jun. 13, 2003. The entire content of all of which isincorporated herein by reference.

FIELD OF INVENTION

The present invention relates to a high saccharide concentrationmedicament and the uses thereof for the treatment, amelioration and/orprophylaxis of symptoms associated with bacterial vaginosis.

BACKGROUND OF INVENTION

Bacterial Vaginosis (BV) is a clinical syndrome characterized bymalodorous discharge. Bacterial Vaginosis is the most common type ofvaginal infection in women of reproductive age, accounting for 45% ofall vulvovaginal infections. Moreover, it has been related to a varietyof upper genital tract infections and obstetrical complications. Theseinclude pelvic inflammatory disease (PID), post-Caesarean endometritis,post hysterectomy pelvic infection, chorioamnionitis, premature ruptureof membranes (PROM) and preterm labor and delivery. The prevention ofthese infections for a woman and her child is an important issue inwomen's health (1).

Fifteen percent of gynecologic patients and 10-30 percent of pregnantwomen have BV, whilst up to 60 percent of women visiting a clinic forsexually transmitted diseases are estimated to suffer from BV (1).

Bacterial Vaginosis has been associated with non-white race, sexualactivity and the intra-uterine device, but no precise studies areavailable. There are indications of sexual transmission of the disease,but other routes are also indicated.

The normal vaginal flora is dominated by lactobacilli which account for95 percent of the bacteria present in the vagina, with other facultativeand anaerobic bacteria present in only small numbers. BacterialVaginosis represents a complex change in the vaginal ecosystemcharacterized by a reduction in the prevalence and concentration oflactobacilli and an increase in the prevalence and concentration ofGardnerella vaginalis, anaerobic gram-negative rods, and Mycoplasmahominis. In BV, a flora consisting primarily of benign lactobacilli isreplaced by a flora consisting of high concentrations of potentiallyvirulent bacteria. Lactobacilli maintain the acid pH in the vagina byproducing lactic acid which maintains a low pH of normally less than4.5. Low pH directly inhibits the growth of anaerobic organisms.Hydrogen peroxide-producing lactobacilli also appear to play a role inlimiting Gardnerella and the anaerobic flora of the vagina (1). Moreoverthe especially virulent Prevotella and Porphyromonas species are presentin particular high numbers in patients with BV (1).

When affected women are symptomatic, they complain predominantly ofvaginal odor. The odor is described as fishy. Patients often refer toembarrassing vaginal odor especially after intercourse. About 90 percentof patients also notice a mild to moderate discharge. Pain symptoms arerare because the infection is not linked to inflammation of the tissue.Patients with BV may not display the symptoms that would normally alerttheir physicians to the infection. In fact, nearly half of the patientswith BV do not complain of excess or malodorous vaginal discharge. Thediagnosis requires three of the following signs to be present:

1. A homogenous, white or grey, noninflammatory discharge that adheresto the vaginal wall.

2. The presence of clue cells (>20% of the epithelial cells in400.times. magnification) on microscopic examination of fresh smears.

3. The pH of vaginal secretions greater than or equals 4.7.

4. A fishy odor of vaginal discharge before or after adding of 10% KOH.

Culture of Gardnerella vaginalis is not recommended as a diagnostictool, as it is not specific.

A study showed that patients with BV had a 5.1-fold higher risk ofpost-partum endometritis following Caesarean section than did patientswith a lactobacilli-dominant flora.

Patients with BV have a four times higher rate of vaginal-cuffcellulitis following abdominal hysterectomy than patients with alactobacillus-dominant flora (1).

The rate of post-abortion pelvic inflammatory disease was three timesless in patients treated with a BV-effective antibiotic related toplacebo-treated patients. Prematurity occurs 1.9 times more commonly,and premature rupture of membranes occurs 3.5 times more commonly inwomen with BV than in those without BV. BV bacteria are frequentlyisolated from amniotic fluid and could play a major role in prematuredelivery (1).

The established medicine offers the treatment of either of twoantibiotics, clindamycin or metronidazole, either topically or by theoral route.

Metronidazole as a 7-day treatment has an 80-90% cure rate after 1month. Side effects are nausea, abdominal cramps and a metallic taste.The patient must refrain from alcohol intake, as it may produce antabuseeffects. It is not recommended in the first trimester of pregnancy.

Clindamycin as a 7-day treatment has equal effects as metronidazole, andits side effects are less, though diarrhea is possible. Concerns aboutClostridium difficile colitis have prevented the widespread use.

Topical application through vaginal preparations has minimized sideeffects; however, this approach is more expensive.

The cure rate is high but a significant proportion of women sufferrelapses and recurrences. There is some evidence that residualbiochemical and microbiological abnormalities persist in these women(2).

Different alternative measures have been advised (live yoghurt bacteria,Lactobacillus acidophilus preparations, acetic acid flushes (severalhits on the Internet). Studies of live yoghurt or Lactobacillusacidophilus have not demonstrated benefits (3).

In U.S. Pat. No. 6,440,949 a method for increasing the acidity in vaginais suggested. The method suggests to administer an amount of 2.5% to 17%(w/v) of one or more saccharides in an acidic medicament. The patenttests different concentrations of saccharides, but none of theconcentrations shows a significant decrease in pH, and furthermore, noneof the concentrations shows elimination of the odor causing bacteria,the Gram negative bacteria (G-b). In U.S. Pat. No. 6,440,949, norelation is shown between the concentration of the saccharide and theresults obtained.

SUMMARY OF INVENTION

The present invention relates to the treatment of one or more of thesymptoms associated with bacterial vaginosis, in particular treatment oramelioration of the odor normally associated with bacterial vaginosis.

Accordingly, in one aspect the invention relates to the use ofsaccharide, said saccharide being fermented by lactic acid bacteria, forthe preparation of a medicament for the treatment, amelioration and/orprophylaxis of one or more symptoms caused by bacterial vaginosis,wherein the medicament comprises at least 20 percent by weight ofsaccharide, and wherein the medicament is substantially free frombacteria.

Furthermore, the fermentation by the lactic acid bacteria in vaginaleads to a high concentration of acid whereby the malign bacteria areinhibited and the symptom-free period after treatment is prolonged. Ifneeded, the treatment can be prolonged without limitations as no adverseside effects occur.

In another aspect the invention relates to a method for the treatment,amelioration and/or prophylaxis of one or more symptoms associated withbacterial vaginosis in an individual, comprising administering aneffective amount of a medicament comprising a saccharide to saidindividual, said saccharide being fermented by lactic acid bacteria,wherein the medicament comprises at least 20 percent by weight of saidsaccharide, and wherein the medicament is substantially free frombacteria.

In yet another aspect the invention relates to a pharmaceuticalcomposition for vaginal application, comprising a saccharide, whereinthe saccharide constitutes at least 20 percent by weight of thepharmaceutical composition, and wherein the composition is substantiallyfree from bacteria.

In a further aspect the present invention relates to a kit-of-partscomprising the pharmaceutical composition as defined above and ananti-fungal agent and/or an antibacterial agent for simultaneous,sequential or separate use.

In another aspect the invention relates to a kit-of-parts comprising thepharmaceutical composition as defined above and at least one pHmeasurement means, for measuring vaginal pH.

DETAILED DESCRIPTION OF THE INVENTION

As described above, the present invention relates in one aspect to theuse of saccharide, said saccharide being fermented by lactic acidbacteria, for the preparation of a medicament for the treatment and/orprophylaxis of one or more symptoms caused by bacterial vaginosis,wherein the medicament comprises at least 20 percent by weight ofsaccharide, and wherein the medicament is substantially free frombacteria.

The symptoms associated with bacterial vaginosis may be:

A homogenous, white or grey, noninflammatory discharge that adheres tothe vaginal wall,

A fishy odor from vagina,

Pruritus of vulva,

Pain.

By the term “symptoms associated with bacterial vaginosis” is meant thatthe medicament may be used for treating the symptoms, independent ofwhether the diagnosis of bacterial vaginosis has been establishedaccording to the criteria set forth above.

The present invention may be used for treating, ameliorating and/orpreventing any one of the above symptoms, and in particular the symptomtreated, ameliorated and/or prevented with the present invention is thefishy odor.

The present inventor has found that a high concentration of saccharidesalleviates the symptoms associated with bacterial vaginosis and prolongsthe period without symptoms after treatment. The medicament comprises atleast 20 percent by weight of saccharide; it is, however, preferred thatthe saccharide medicament comprises even more saccharide. In a preferredembodiment the medicament is a saccharide suspension or pure saccharide,such as a saturated saccharide suspension, such as dry powder in tabletsor capsules. Accordingly, the medicament preferably comprises at least25 percent by weight of the saccharide, such as at least 40 percent byweight of saccharide, such as at least 50 percent by weight ofsaccharide, such as at least 75 percent by weight of saccharide, such asat least 90 percent by weight of saccharide, such as at least 95 percentby weight of saccharide, such as at least 98 percent by weight ofsaccharide, such as 100 percent by weight of saccharide. The term“percent by weight” is used in its normal meaning, i.e. grammes (g) ofsaccharide in grammes of the medicament.

It is of importance that the medicament is substantially free frombacteria, in particular substantially free from lactic acid bacteria. Bythe term “substantially free from bacteria” is meant that the medicamentincludes less than 10₅ bacteria per dosage, such as less than 10⁴bacteria per dosage, such as less than 10₃ bacteria per dosage, such asless than 10₂ bacteria per dosage. In particular the medicament includesless than 10₅ lactic acid bacteria per dosage, such as less than 10₄lactic acid bacteria per dosage, such as less than lactic acid 10₃bacteria per dosage, such as less than 10₂ lactic acid bacteria perdosage. Lactic acid bacteria are for example Lactobacillus acidophilus,Streptococcus thermophilus, Bifidobacterium longum.

Furthermore, it is preferred that the medicament according to theinvention also treats or prevents the bacterial vaginosis. This may beexamined by measuring the vaginal pH. A vaginal pH is normally less than4.5. Accordingly, a decrease in vaginal pH to below 4.7, more preferablybelow 4.5, is an indication that the bacterial vaginosis has beentreated.

The saccharide according to the invention is any suitable saccharide,wherein the saccharide is fermented by lactic acid bacteria. Preferablythe saccharide is not fermented by Gardnerella vaginalis.

Accordingly, in a preferred embodiment the saccharide is selected from adisaccharide and a monosaccharide, such as a saccharide selected fromlactose and saccharose, preferably selected from lactose. When usinglactose, it is preferred that the lactose is in its originaldisaccharide form, and not degraded.

The medicament may comprise one type of saccharide or a mixture ofsaccharides, wherein all saccharides are suitable according to theinvention.

The medicament according to the invention is useful for treating,ameliorating, and/or preventing symptoms associated with bacterialvaginosis as defined above independent of the bacteria causing thevaginosis. In particular the medicament is used for treating,ameliorating and/or preventing symptoms caused by bacteria selected fromGardnerella vaginalis, Gram negative rods, and Mycoplasma hominis. Morespecifically the medicament is used for treating, ameliorating and/orpreventing symptoms caused by bacteria selected from anaerobic Gramnegative rods.

The medicament according to the invention is preferably applied directlyinto the vagina, and therefore, the medicament is preferably formulatedfor topical application. Accordingly, the medicament may have anysuitable form for topical administration. In one embodiment themedicament is in the form of a vaginal suppository gel. In anotherembodiment the medicament is in the form of a vaginal capsule. In yetanother embodiment the medicament is in the form of a vaginal tablet. Ina further embodiment the medicament is in the form of a suspension.

The medicament preferably comprises a pharmaceutical compositioncomprising a saccharide as described herein optionally mixed withsuitable pharmaceutically acceptable additives and/or carriers. Thesaccharide may be formulated in any suitable manner, for example in formof a monohydrate.

Examples of pharmaceutically acceptable additives and carriers arepolyethylene glycols, glycerol, agar agar, carrageenan, modifiedstarches, stearates, and water. In particular it is preferred that theadditives or carriers are not based on protein, since a protein sourcemay counteract the beneficial effects of the medicament. In a preferredembodiment the additive is magnesium stearate or sodium stearate. In oneaspect the invention further relates to a pharmaceutical compositioncomprising the saccharide as described above in the concentrationsdescribed above and optionally further comprising pharmaceuticallyacceptable additives and/or carriers.

The pH of the pharmaceutical composition before application to thevagina is preferably in the range of from 5.5 to 8.0, such as from 6.5to 7.5, more preferably about 7.0.

The conservation of the product is preferably secured by low wateractivity, optionally aseptic production and packaging, and if needed,sorbic acid or paraben preservatives.

The medicament according to the invention has a long shelf life atambient temperature.

In a further aspect the invention relates to a method of treating,ameliorating and/or preventing symptoms associated with bacterialvaginosis, wherein the method comprises administering an effectiveamount of a medicament comprising a saccharide, wherein the saccharideis as defined above.

The medicament may be administered one or more times per day, asnecessary for a period of from 1 to 7 days, but if needed, the treatmentcan be prolonged without limitations.

Furthermore, the medicament may be administered intermittently accordingto the needs of the individual to be treated.

The medicament is preferably administered in dosages, wherein one dosageunit may be from 10 mg to 10 g of medicament. In a more preferredembodiment, the dosage unit is from 1-5 g of medicament.

The saccharides are the essential active component of the medicamentaccording to the invention, and can fulfil the object of the invention.However, for some treatment regimens, it is preferred that themedicament further includes an effective amount of another medicament.

Accordingly, in one embodiment the medicament further includes ananti-fungal agent. Examples of anti-fungal agents are ketoconazole,terconazole, itraconazole, and fluconazole.

In another embodiment the medicament further includes an effectiveamount of an anti-bacterial agent. Examples of suitable anti-bacterialagents are metronidazole and clindamycin.

In another aspect the invention relates to a combination product or akit-of-parts product comprising the pharmaceutical composition asdefined above and an antifungal agent and/or an anti-bacterial agent forsimultaneous, sequential or separate use. The anti-fungal andanti-bacterial agent is preferably as described above.

In order to test the functionality of the medicament, the medicament ofthe invention may also be commercialized as a kit-of-parts comprisingthe pharmaceutical composition as defined above and at least one pHmeasurement means, for measuring vaginal pH.

The pH measuring means is preferably a pH indicator strip, such as anindicator strip from Merck showing pH in the interval 4.0-7.0. The pHmeasuring means may be applied directly to the vaginal mucosa formeasurement.

EXAMPLES Example 1

Vaginal Suppository Gel Ingredients: Lactose, spray-dried (alphamonohydrate)   40% Macrogol (polyethylene glycols) 1000   5% Macrogol(polyethylene glycols) 3000   5% Parabens*  0.1% Disodium hydrogenphosphate  0.1% Water 49.8% pH 7.0 *8:2 mixture of methyl- and propylpars hydroxy benzoate

The ingredients are mixed homogeneously, the resulting suspension issterilized by means of heat and dispensed aseptically into sterilepackaging.

1 dosage=1-3 ml

Example 2

Vaginal suppository gel Lactose, spray-dried (alpha monohydrate)   40%Glycerol   15% Agar agar   2% Disodium hydrogen phosphate  0.1% Water42.9% pH 7.0

The ingredients are heated to boiling point and mixed homogeneously.They are then sterilized by heat and dispensed aseptically into sterilepackaging.

1 dosage=1-3 ml

Example 3

Vaginal suppository gel Lactose, spray-dried (alpha monohydrate)  50%Glycerol  15% Carrageenan (Iota or mixture) 0.8% Disodium hydrogenphosphate 0.1% CaCl₂ 0.1% Water  34% pH 7.0

The ingredients are heated to boiling point and mixed homogeneously.They are then sterilized by heat and dispensed aseptically into sterilepackaging.

1 dosage=1-3 ml

Example 4

Vaginal capsuleLactose, spray-dried (alpha monohydrate)Encapsulated in capsules produced from modified starchesCapsules are prepared in a conventional manner.Dosage: 0.5-3 grammes

Example 5

Vaginal tablets Lactose, Fast Flo 90% Starch 1500 (modified starch) 10%

The ingredients are mixed homogeneously, and the resulting mixture ispressed into tablets in a conventional manner. Raw materials of goodmicrobiological quality and hygienic production facilities secure therequired microbiological quality. Dosage: 0.5-3 grammes

Example 6

Vaginal tablets Lactose, spray-dried (alpha monohydrate) 95%Polyethylene glycol  5%

The ingredients are mixed homogeneously, and the resulting mixture ispressed into tablets in a conventional manner. Raw materials of goodmicrobiological quality and hygienic production facilities secure therequired microbiological quality.

Dosage: 0.5-3 grammes

Example 7

Vaginal tablets Lactose, spray-dried (alpha monohydrate) 100%

The lactose is pressed into tablets in a conventional manner. Rawmaterials of good microbiological quality and hygienic productionfacilities secure the required microbiological quality.

Dosage: 0.5-3 grammes

Example 8

Suspension Lactose, spray-dried (alpha monohydrate)   50% Disodiumhydrogen phosphate  0.1% Water 49.9% pH 7.0

The ingredients are mixed homogeneously, and the resulting suspension issterilized by means of heating.

1 dosage=1-3 ml by use of an application device

Example 9 Treatment

A female had suffered from discomfort and vaginal secretions of fishysmell recurring after two 7-day treatments with metronidazole. Thevaginal pH was approximately 5.3, varying between 5.0 and 5.5.

A lactose suspension (1-3 ml) as prepared in Example 8 was instilledinto the vagina twice daily. After approximately 24 hours the pH loweredto 4.7 and the fishy odor disappeared. Continuous application once a dayfurther lowered the pH down to approximately 4.4. The treatment wascontinued for 4 days.

After 4 days symptoms such as the fishy odor recurred; however, thesymptoms disappeared after one day of the treatment described above.

REFERENCES

-   1. SOGC Clinical Practice Guidelines No. 14 Mar. 1997. Bacterial    vaginosis.-   2. Priestley, Cecilia J F, and G R Kinghorn. “Bacterial Vaginosis.”    British Journal of Clinical Practice 50, No. 6 (September 1996):    331-334.-   3. Larsson, P. G. Treatment of bacterial vaginosis. Int. J. STD AIDS    1992; 3: 239-247.-   4. Gardnerella vaginalis (2003) M. J. Pickett, James R. Greenwood,    Sydney M. Harvey.

1. A method for the treatment and/or amelioration of one or moresymptoms of bacterial vaginosis, comprising administering to anindividual having one or more symptoms of bacterial vaginosis apharmaceutical dosage unit of 10 mg to 10 g in the form of a vaginalsolution or gel, said pharmaceutical dosage unit consisting essentiallyof at least 20% by weight of lactose monohydrate as the only activeingredient, and wherein said dosage unit includes less than 10⁵bacteria, thereby treating and/or ameliorating symptoms of bacterialvaginosis.
 2. The method according to claim 1, wherein one symptom isunpleasant vaginal odor.
 3. The method according to claim 1, wherein asymptom is pruritus of vulva.
 4. The method according to claim 1,wherein the lactose monohydrate is substantially not fermented byGardnerella vaginalis.
 5. The method according to claim 1, wherein thebacterial vaginosis is caused by bacteria selected from Gardnerellavaginalis, Gram negative rods, and Mycoplasma hominis.
 6. The methodaccording to claim 5, wherein the bacterial vaginosis is caused bybacteria selected from anaerobic Gram negative rods.
 7. The methodaccording to claim 1, wherein the pharmaceutical dosage unit isformulated for topical application.
 8. The method according to claim 1,wherein the pharmaceutical dosage unit is in the form of a vaginalsolution.
 9. The method according to claim 1, wherein the pharmaceuticaldosage unit is in the form of a vaginal suppository gel.
 10. The methodaccording to claim 1, wherein a dosage unit is from 1-5 g.
 11. Themethod according to claim 1, wherein the pharmaceutical dosage unitcomprises one or more pharmaceutically acceptable additives and carriersselected from the group consisting of: polyethylene glycols, glycerol,agar agar, carrageenan, modified starches, stearates and water.
 12. Amethod for reducing vaginal pH to below 4.7, comprising administering toan individual having one or more symptoms of bacterial vaginosis aneffective amount of a pharmaceutical dosage unit of 10 mg to 10 g in theform of a vaginal solution or gel for vaginal application saidpharmaceutical dosage unit consisting essentially of: a) at least 20percent by weight of lactose monohydrate as the only active ingredient,and b) optionally one or more pharmaceutically acceptable additives,carriers and/or preservatives, wherein said dosage unit includes lessthan 10⁵ bacteria.
 13. The method of claim 12 wherein the vaginal pH isreduced to below 4.5.
 14. The method of claim 12 further comprisingmeasuring said vaginal pH subsequent to said administering.